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For, 1111-9 I Request for Taxpayer Give Form to the
<br /> (Rev.December 2011) Identification Number and Certification requester.Do not
<br /> Department of the Treasury send to the IRS.
<br /> Internal Revenue Service
<br /> Name(as shown on your income tax return)
<br /> Cass County Government
<br /> N Business name/disregarded entity name,if different from above
<br /> a
<br /> rn
<br /> Check appropriate box for federal tax classification:
<br /> ❑ Individual/sole proprietor ❑ C Corporation ❑s Corporation ❑ Partnership ❑Trust/estate
<br /> 6 v ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)• ❑Exempt payee
<br /> c. 4 Other(see Instructions)•
<br /> Local Government
<br /> 15 Address(number,street,and apt or suite no.) Requester's name and address(optional)
<br /> a 211 9th St S
<br /> a City,state,and ZIP code
<br /> Cn Fargo,ND,58103
<br /> List account number(s)here(optional)
<br /> Part I Taxpayer Identification Number(TIN)
<br /> Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line I Social security number
<br /> to avoid backup withholding.For individuals,this Is your social security number(SSN).However,for a
<br /> resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other — —
<br /> entities,It is your employer Identification number(EIN).If you do not have a number,see How to get a
<br /> 77N on page 3.
<br /> Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer Identification number
<br /> number to enter.
<br /> 4 5 - 6 0 0 2 2 0 5
<br /> Part II Certification
<br /> Under penalties of perjury,I certify that
<br /> 1. The number shown on this form Is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
<br /> 2. I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
<br /> Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
<br /> no longer subject to backup withholding,and
<br /> 3. I am a U.S.citizen or other U.S.person(defined below).
<br /> Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
<br /> because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
<br /> interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
<br /> generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
<br /> instructions on page 4.
<br /> Sign Signature of �/
<br /> Here u.s.person• � �"' 7,77/ c. f Date• /�-3/ 3
<br /> General instr tions Note.If a requester gives you a form other than Form W-9 to request
<br /> your TIN,you must use the requester's form if It is substantially similar
<br /> Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
<br /> noted. Definition of a U.S.person.For federal tax purposes,you are
<br /> Purpose of Form considered a U.S.person if you are:
<br /> A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien,
<br /> obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or
<br /> example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
<br /> you paid,acquisition or abandonment of secured property,cancellation •An estate(other than a foreign estate),or
<br /> of debt,or contributions you made to an IRA.
<br /> Use Form W-9 only H you are a U.S.person(including a resident •A domestic trust(as defined in Regulations section 301.7701-7).
<br /> alien),to provide your correct TIN'to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or
<br /> requester)and,when applicable,to: business in the United States are generally required to pay a withholding
<br /> 1.Certify that the TIN you are giving is correct(or you are waiting for a tax on any foreign partners'share of income from such business.
<br /> number to be issued), Further,in certain cases where a Form W-9 has not been received,a
<br /> partnership Is required to presume that a partner is a foreign person,
<br /> 2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
<br /> 3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United
<br /> payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
<br /> allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income.
<br /> is not subject to the withholding tax on foreign partners'share of
<br /> effectively connected income.
<br /> Cat.No.10231X Form W-9(Rev.12-2011)
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